Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration

[摘要] Objective Timely preventive care can substantially reducerisk of recurrent vascular events or death after a transientischaemic attack (TIA). Our objective was to understandpatient and facility factors influencing preventive carequality for patients with TIA in the US Veterans HealthAdministration (VHA).Methods We analysed administrative data from aretrospective cohort of 3052 patients with TIA cared forin the emergency department (ED) or inpatient setting in110 VHA facilities from October 2010 to September 2011.A composite quality indicator (QI score) pass rate wasconstructed from four process-related quality measures—carotid imaging, brain imaging, high or moderate potencystatin and antithrombotic medication, associated with theED visit or inpatient admission after the TIA. We testeda multilevel structural equation model where facilityand patient characteristics, inpatient admission, andneurological consultation were predictors of the resident’scomposite QI score.Results Presenting with a speech deficit and higherCharlson Comorbidity Index (CCI) were positively relatedto inpatient admission. Being admitted increased thelikelihood of neurology consultation, whereas history ofdementia, weekend arrival and a higher CCI score madeneurological consultation less likely. Speech deficit, higherCCI, inpatient admission and neurological consultationhad direct positive effects on the composite qualityscore. Patients in facilities with fewer full-time equivalentneurology staff were less likely to be admitted or tohave a neurology consultation. Facilities having greaterorganisational complexity and with a VHA stroke centredesignation were more likely to provide a neurologyconsultation.Conclusions Better TIA preventive care could be achievedthrough increased inpatient admissions, or throughenhanced neurology and other care resources in the EDand during follow-up care.

[学科分类] 药学